An overview of global CME/CPD systems.

PURPOSE: Engagement in CME/CPD has a positive impact on healthcare professionals' (HCPs) knowledge, skills, and performance, and on patient outcomes, therefore it is critical to better understand the components of CME/CPD systems that foster engagement, high-quality education, and impact. METHODS: An assessment of CME/CPD systems was conducted using a mixed-methods approach that included interviews with in-country subject matter experts and qualitative and quantitative data from practicing in-country physicians. RESULTS: Results demonstrate areas of consistency in CME/CPD systems across world regions that included: types of educational providers; types of credit; educational formats; self-tracking of participation; high-degree of compliance when education is mandatory; overall satisfaction with available education; strong support for interprofessional education; and lack of alignment or evaluation of engagement in education with population health outcomes. Areas of variation included: whether engagement in education is required as a condition to practice medicine; whether regulations are uniformly applied; if mechanisms to ensure independence existed; and physician perceptions of independence. CONCLUSION: Results of this assessment maybe used by a variety of different stakeholders to assess how well country-level CME/CPD systems are meeting the needs of practicing physicians and determine what, if any, changes might need to be implemented to improve outcomes.

An Overview of Continuing Medical Education/Continuing Professional Development Systems in China: A Mixed Methods Assessment.

Aims of this assessment were to describe requirements for physicians to engage in CME/CPD; explore perceptions of In-Country SMEs of their CME/CPD systems; describe perceptions of In-Country physicians about interprofessional continuing education (IPCE) and independent CME/CPD; and provide recommendations that may be adopted to improve quality and effectiveness. This assessment used a mixed-methods approach that included 1:1 interviews with in-country subject matter experts and an electronic survey capturing qualitative and quantitative data from practicing in-country physicians. This assessment reflects a country invested in the education of its physician workforce. CME/CPD systems have embedded governance structures, organizations authorized to provide education, and a recognized credit system. Governing bodies have implemented regulations to limit influence from commercial interest organizations on CME/CPD, and there is opportunity to expand delivery systems to reach physicians across diverse geographic regions, better align content to individual physicians' gaps and learning needs, and reduce cost. There is opportunity to invest in IPCE within a country with a strong professional hierarchy system. This assessment reflects CME/CPD systems that are relatively mature and identifies several opportunities to expand and enhance systems to better meet educational needs of physicians and to positively impact practice and patient outcomes.

Effects of a competence-based approach for clerkship teaching under alternating clinical placements: An explanatory sequential mixed-methods research.

BACKGROUND: It is unclear whether alternating placements during clinical clerkship, without an explicit emphasis on clinical competencies, would bring about optimal educational outcomes. METHODS: This is an explanatory sequential mixed-methods research. We enrolled a convenience sample of 41 eight-year programme medical students in Sun Yat-sen University who received alternating placements during clerkship. The effects of competence-based approach (n = 21) versus traditional approach (n = 20) to clerkship teaching were compared. In the quantitative phase, course satisfaction was measured via an online survey and academic performance was determined through final scores on summative assessment. Then, in the qualitative phase, students were invited for semi-structured interviews about their learning experiences, and the transcripts were used for thematic analysis. RESULTS: Quantitative findings showed that students in the study group rated high course satisfaction and performed significantly better in their final scores compared with those in the control group. Qualitative findings from thematic analysis showed that students were relatively neutral about their preference on placement models, but clearly perceived, capitalised, and appreciated that their competencies were being cultivated by an instructor who was regarded as a positive role model. CONCLUSION: A competence-based approach to clerkship teaching resulted in better course satisfaction and academic performance, and was perceived, capitalised, and appreciated by students.

Reflecting on Experiences of Senior Medical Students' External Clinical Teaching Visits in General Practice Placements: A Pilot Study.

Purpose: Australian general practice training uses external clinical teaching (ECT) visits for formative work-based assessments. ECT visits appoint senior general-practitioners (GPs) observe trainee GPs' consultations, provide feedback, and make performance-enhancing recommendations. As ECT visits are one of the best assessment tools in Australian GP training, there is limited evidence of its use in undergraduate teaching. This study aims to introduce ECT visits and evaluate assessment tools during senior medical students' GP placement. Methods: This study included external and internal GP supervisors and twenty-five Chinese and Australian students during GP placements. The supervisors provided structured in-person feedback, while the ECT assessment tool used a standardised, validated feedback platform to assess every component of a consultation. Students' feedback was recorded and collected by both internal and external supervisors, and then semantically analysed by external supervisors. Results: Twenty-five ECT visit feedbacks were collected and analysed semantically. All participating students rated ECT visits excellently and confirmed the relevance of assessment tools for discussions with supervisors to achieve the designed learning outcomes. Chinese students rated the assessment tools as innovative from a cultural perspective and recommended the ECT visit teaching model and assessment tools to their home university, whereas Australian students suggested more ECT visits during GP placements. Time management was a limitation for both the students and supervisors. Conclusion: ECT visit is an innovative placement teaching model and work-based assessment tool for senior medical students' GP placements, and is rated as the most preferred formative assessment tool. The limitations of this study include small group of students/supervisors and lack of patient feedback; however, all of these limitations can be overcome by involving multiple GP clinics in ongoing large-scale study. ECT visits can be introduced quantitatively into students' GP placement curricula to improve clinical reasoning, learning, and quality assurance with assessments during clinical placements.

Intensive Glycemic Therapy in Type 2 Diabetes Patients With Cardiac Autonomic Dysfunction: The ACCORD Trial.

OBJECTIVE: To assess whether the presence of cardiac autonomic dysfunction denoted by low heart rate variability (HRV) modifies the effect of intensive glycemic therapy on outcomes in patients with type 2 diabetes. PATIENTS AND METHODS: This study included 7946 participants in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial from January 2001 through June 2009. Heart rate variability measures included standard deviation of all normal-to-normal intervals (SDNN) and root mean square of successive differences between normal-to-normal intervals (rMSSD). Abnormal values were defined based on less than the 10th percentile for SDNN and rMSSD. RESULTS: Compared with standard therapy, intensive therapy was associated with improved primary outcome (composite of cardiovascular events) in the low-HRV group (SDNN: HR, 0.57; 95% CI, 0.39 to 0.84; rMSSD: HR, 0.57; 95% CI, 0.38 to 0.84), but not in the normal-HRV group (SDNN: HR, 0.90; 95% CI, 0.77 to 1.05; rMSSD: HR, 0.90; 95% CI, 0.77 to 1.05). A similar pattern was found for coronary heart disease. Conversely, intensive therapy had a neutral effect on all cause death in the low-HRV group (SDNN: HR, 0.88; 95% CI, 0.54 to 1.41; rMSSD: HR, 0.71; 95% CI, 0.43 to 1.17;), but increase risk of all-cause death in the normal-HRV group (SDNN: HR, 1.21; 95% CI, 1.00 to 1.46; rMSSD: HR, 1.25; 95% CI, 1.03 to 1.51). Intensive therapy induced a greater risk of hypoglycemia in the normal-HRV group than that in the low-HRV group. CONCLUSION: Cardiac autonomic dysfunction expressed as low HRV identified subpopulations in ACCORD with more benefits and less harms from intensive therapy.

Interplay of heart rate variability and resting heart rate on mortality in type 2 diabetes.

AIMS: Heart rate variability (HRV) and resting heart rate (RHR) are usually analyzed and interpreted separately. We aimed to assess the interplay of HRV and RHR on mortality in type 2 diabetes. METHODS: The study included 7,529 participants from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. HRV metrics included standard deviation of all normal-to-normal intervals (SDNN) and root mean square of successive differences between normal-to-normal intervals (rMSSD). Abnormal values were defined based on <25th percentile for HRV and >75th percentile for RHR. Interactions of HRV status and RHR status were tested on multiplicative and additive scales. Results were validated in a subset of patients with type 2 diabetes (n = 745) from the Multi-Ethnic Study of Atherosclerosis. RESULTS: Low SDNN was associated with increased all-cause mortality in the high RHR group (HR 1.60; 95% CI 1.29-1.97), but not in the normal RHR group. Compared with those who had neither low SDNN nor high RHR, the presence of either low SDNN or high RHR was not significantly associated with an increased risk of all-cause mortality. In contrast, the combination of low SDNN and high RHR was associated with a significantly increased risk of all-cause mortality (HR 1.68; 95% CI 1.43-1.97). Significant multiplicative and additive interactions were found between HRV status and RHR status on risk of all-cause mortality (all Pinteraction < 0.05). Similar findings were observed for cardiovascular mortality, in analyses using rMSSD, and in the Multi-Ethnic Study of Atherosclerosis. CONCLUSIONS: The association between HRV and mortality risk is modified by RHR levels. Furthermore, low HRV and high RHR have interdependent and synergistic associations with mortality risk.

Reflecting on Students' Experiences of an Innovative Teaching Model During Aged Care Visit in Clinical Placements: A Qualitative Pilot Study.

Purpose: Clinical placement teaching could be challenging due to time constraints, lack of effective teaching models and consensus approaches. Learner-centred approach facilitated deeper learning by demonstrating "seeing-patients-under-supervision" being ideal during Residential-Aged-Care-Facility (RACF)-visit in GP clinical placements. The study aimed to reflect on the students' experiences in aged-care visits by applying an innovative teaching model of "students-being-the-GP-clinician-in-charge-of-RACF-visit-ward-round-under-the-supervision-of-clinical-supervisor". Through students' reflections, this study identified 12 commonly managed RACF problems to be introduced into the curriculum to optimise clinical reasoning learning during RACF-visit. Methods: This qualitative study used online surveys and interviews. All participating students reported all the encountered cases during the RACF visit through an online survey. The participating students acted as GP in charge of all clinical interactions with patients, caregivers, and nurses during RACF visits and final management plan discussions with GP supervisors to ensure clinical-service safety and teaching-and-learning quality. The interview questionnaires applied standard-and-open-ended-questions to examine the impact of this innovative teaching model on clinical-reasoning-learning, clinical-competence-improvement, Objective Structured Clinical Exam (OSCE) preparation, limitations-from-students'-patients'-and-supervisors' perspectives, and intern readiness. Results: An online survey summarising students' encountered cases was returned by 30 students. The 12 most commonly-managed problems were tabulated. Falls, urinary tract infections, and behavioural and psychological symptoms of dementia were the three most commonly-managed problems. All thirty students' reflections indicated the positive impact of the innovative-teaching-models on "Improving-Clinical-Reasoning-Learning", "Enhancing-Clinical-Competency", "Enriching-Salient-Learning-Points", "Facilitating-Feedback-Discussion-with-Supervisor", "Strengthening-OSCE-exam-preparation", "Understanding-the-Limitation-from-students'-patients'-and-supervisors'-perspectives", "Enabling-intern-readiness". Twelve students' individual reflections were demonstrated. Conclusion: This qualitative pilot study demonstrated through students' reflection that "Student-doctor-in-charge-of-nursing-home-round" is an innovative teaching model for clinical reasoning learning. This model extended the concepts of "cognitive-apprenticeship" in the context of modern medical education. Students' reflections and summary of commonly managed problems indicated the need for further study to verify the feasibility of implementing this teaching model in the formal curriculum and creating a RACF-visit-specific curriculum for students.

Potential Roles of Glucagon-Like Peptide 1 Receptor Agonists (GLP-1 RAs) in Nondiabetic Populations.

Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) have been observed in several large cardiovascular outcome trials to significantly reduce the incidence of major cardiovascular event (MACE) with type 2 diabetic patients. The clinical trials of GLP-1 RAs, including lixisenatide, exenatide, liraglutide, semaglutide, albiglutide, and dulaglutide, are associated with a significantly 14% lower risk of MACE in patients with T2DM and a history of CV disease, and with a nonsignificantly 6% lower risk in patients without history of CV disease. Some of the interpretation with GLP-1 RA trials suggested the possible role of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in primary prevention of cardiovascular diseases in nondiabetic individual, echoed by a recent editorial redefining the role of GLP-1 RAs being beyond glycaemic control. The narrative review provides an in-depth insight into GLP-1 RA use guideline in different countries and regions of the world and examines the safety and concern of GLP-1 RA use. The narrative review draws the comparison of GLP-1 RA use between diabetic and nondiabetic individual in terms of cardiovascular and metabolic benefits and points out the direction of future clinical trials of GLP-1 RAs in nondiabetic individuals. The focus of the review is on GLP-1 RAs' preventive roles in nondiabetic individuals with cardiovascular disease, chronic kidney diseases, obesity, dyslipidaemia, hypertension, nonalcoholic fatty liver diseases, polycystic ovarian syndrome (PCOS), and perioperative complications of bariatric surgery, albeit in small studies and subset analysis of clinical trials of diabetic patients.

Risk Stratification and Efficacy of Spironolactone in Patients with Heart Failure with Preserved Ejection Fraction: Secondary Analysis of the TOPCAT Randomized Clinical Trial.

PURPOSE: We aimed to develop a simple risk score for patients with HFpEF and assessed the efficacy of spironolactone across baseline risk. METHODS: We developed risk stratification scheme for cardiovascular death in placebo arm of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial (TOPCAT). We screened candidate risk indicators and determined strong risk predictors using COX regression. The absolute risk reduction (ARR) in cardiovascular death with spironolactone was evaluated across baseline risk groups. COX regressions were performed to assess the hazard ratios (HRs) of spironolactone therapy for cardiovascular death and drug discontinuation in each risk category. RESULTS: A simple risk score scheme was constructed based on five risk indicators weighted by estimates from the model, including age, diastolic blood pressure, renal dysfunction, white blood cell, and left ventricular ejection fraction. The risk score scheme showed good discrimination in placebo cohort (C index=0.70). ARR with spironolactone therapy was observed only in patients at very high risk (7.9%). Spironolactone therapy significantly reduced the risk of cardiovascular death in the very high-risk group (HR: 0.57; 95%CI, 0.39-0.84; P =0.005 and P for interaction 0.03) but showed similar risk of drug discontinuation across risk categories (P for interaction=0.928). CONCLUSION: This simple risk score stratifies patients with HFpEF by their baseline risk of cardiovascular death. Patients at very high risk derive great benefits from spironolactone therapy. This easy-to-use risk score provides a practical tool that can facilitate risk stratification and tailoring therapy for those who benefit most from spironolactone. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00094302.

Sodium-Glucose Cotransporter-2 Inhibitor (SGLT2i) as a Primary Preventative Agent in the Healthy Individual: A Need of a Future Randomised Clinical Trial?

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are a relatively novel class of drug for treating type 2 diabetes mellitus (T2DM) that inhibits glucose reabsorption in the renal proximal tubule to promote glycosuria and reduce blood glucose levels. SGLT2i has been clinically indicated for treating T2DM, with numerous recent publications focussing on both primary and secondary prevention of cardiovascular and renal events in Type 2 diabetic patients. The most recent clinical trials showed that SGLT2i have moderately significant beneficial effects on atherosclerotic major adverse cardiovascular events (MACE) in patients with histories of atherosclerotic cardiovascular disease. In this review and analysis, SGLT2i have however demonstrated clinically significant benefits in reducing hospitalisation for heart failure and worsening of chronic kidney disease (CKD) irrespective of pre-existing atherosclerotic cardiovascular disease or previous heart failure history. A meta-analysis suggests that all SGLT2 inhibitors demonstrated the therapeutic benefit on all-cause and cardiovascular mortality, as shown in EMPAREG OUTCOME study with a significant decrease in myocardial infarction, without increased stroke risk. All the above clinical trial recruited type 2 diabetic patients. This article aims to postulate and review the possible primary prevention role of SGLT2i in healthy individuals by reviewing the current literature and provide a prospective overview. The emphasis will include primary prevention of Type 2 Diabetes, Heart Failure, CKD, Hypertension, Obesity and Dyslipidaemia in healthy individuals, whom are defined as healthy, low or intermediate risks patients.

Intensity of Glycemic Exposure in Early Adulthood and Target Organ Damage in Middle Age: The CARDIA Study.

AIM: To determine whether long-term intensity of glycemic exposure (IGE) during young adulthood is associated with multiple target organs function at midlife independent of single fasting glucose (FG) measurement. METHODS: We included 2,859 participants, aged 18-30 years at Y0, in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. IGE was calculated as the sum of (average FG of two consecutive examinations × years between the examinations) over 25 years. Target organs function was indicated by cardiac structure, left ventricular (LV) systolic function, LV diastolic function, coronary artery calcium (CAC), and urine albumin-to-creatinine ratio (UACR) at Y25. We evaluated the associations between IGE with target organs function using linear regression models and estimated the associations between IGE with numbers of organs involved (0, 1, or ≥ 2 organs) using multinomial logistic regression models. RESULTS: A 1-SD increment of IGE was significantly associated with worse target organs function after multivariable adjustment: left ventricular mass (ß [SE], 5.468 [1.175]); global longitudinal strain (ß [SE], 0.161 [0.071]); E/e' ratio (ß[SE], 0.192 [0.071]); CAC score (ß [SE], 27.948 [6.116]); and log UACR (ß [SE], 0.076 [0.010]). Besides, IGE was independently associated with having ≥ 2 organs involved in both overall population (OR [95% CI], 1.48 [1.23, 1.41], P < 0.001) and subgroups stratified by diabetes at Y25. CONCLUSION: Higher intensity of glycemic exposure during young adulthood was independently associated with subclinical alterations of target organs function at midlife. Our findings highlight the importance of early screening and management of IGE in youth.

Behavioral Factors Mediating the Impact of Educational Attainment on Incident Heart Failure　- A Mediation Analysis.

BACKGROUND: To examine the association of low educational attainment with incident heart failure (HF) and explore potential behavioral mediators of the causal pathway.Methods and Results:A total of 12,109 participants in the Atherosclerosis Risk in Communities Study (ARIC) were included. Educational attainment was measured at baseline, and the risk of HF across educational attainment groups was assessed by Cox proportional hazards models. Using mediation analysis, we evaluated the mediating role of behavioral factors in the causal pathway between educational attainment and HF. During a median follow-up of 25.1 years, 2,407 cases (19.9%) of HF occurred. Educational attainment showed an inverse association with HF risk (hazard ratio (HR), 1.41; 95% confidence interval (CI), 1,26-1.57 for low educational attainment; HR, 1.13; 95% CI, 1.02-1.25 for medium educational attainment). In the mediation analysis, the association between educational attainment and HF was partially mediated by income, waist-to-hip ratio, current smoking, body mass index, current drinking, sports and physical activity, which explained 24.3%, 20.2%, 13.8%, 10.1%, 7.7%, 7.3% and 4.5%, respectively, of the relationship. In total, all mediators contributed 56.3% of the total effect. CONCLUSIONS: Low educational attainment was associated with increased risk for HF. Income, obesity and current smoking mediated a great proportion of the total effect of educational attainment on HF. Our results provide underlying insights for the development of targeted public health interventions to reduce educational disparities on HF incidence.

Urban index and lifestyle risk factors for cardiovascular diseases in China: A cross-sectional study.

China is at a stage of rapid urbanization over the past decades, and the association of urbanization with cardiovascular disease has been confirmed by previous studies. However, few studies assessed the association of urbanization with cardiovascular risk factors, especially in Chinese population. We conducted a cross-sectional, populational-based study, using data from China Health and Nutrition Survey (CHNS) in 2009. The logistic regression was used to assess the association of urbanization measured by urban index with cardiovascular risk factors (diabetes mellitus, hypertension, dyslipidemia, obesity, smoking, physical activity and fruits and vegetables consumption), varied with sex. The current study included 18,887 participants enrolled (mean age 39.8 ± 19.8 years; 52.2% female) who live in China. In regression model, the urban index was significantly associated with the variations of cardiovascular risk factors for male, including diabetes (OR 1.34, 95% CI: 1.22-1.48), hypercholesterolemia (OR 1.15, 95% CI: 1.09-1.22), never smoking (OR 0.92, 95% CI: 0.89-0.96), higher fruits and vegetables consumptions (OR 0.93, 95% CI: 0.87-0.99), higher body mass index (BMI) (OR 1.16, 95% CI: 1.10-1.22), and higher physical activity (OR 0.69, 95% CI: 0.66-0.73). Compared with the male, the associations of urban index with cardiovascular risk factors for female were similar, but not for BMI (OR 1.00, 95% CI: 0.96-1.05). The present finding emphasizes the changes of cardiovascular risk factors associated with urbanization in China, and indicated that close attention should be paid to the risk of hypercholesterolemia, diabetes and men's obesity in the process of urbanization.

Association of Mid- to Late-Life Blood Pressure Patterns With Risk of Subsequent Coronary Heart Disease and Death.

Background: The elevated blood pressure (BP) at midlife or late-life is associated with cardiovascular disease and death. However, there is limited research on the association between the BP patterns from middle to old age and incident coronary heart disease (CHD) and death. Methods: A cohort of the Atherosclerosis Risk in Communities (ARIC) Study enrolled 9,829 participants who attended five in-person visits from 1987 to 2013. We determined the association of mid- to late-life BP patterns with incident CHD and all-cause mortality using multivariable-adjusted Cox proportional hazards models. Results: During a median of 16.7 years of follow-up, 3,134 deaths and 1,060 CHD events occurred. Compared with participants with midlife normotension, the adjusted hazard ratio for all-cause mortality and CHD was 1.14 (95% CI, 1.04-1.25) and 1.28 (95% CI, 1.10-1.50) in those with midlife hypertension, respectively. In further analyses, compared with a pattern of sustained normotension from mid- to late-life, there was no significant difference for the risk of incident death (HR, 1.15; 95% CI, 0.96-1.37) and CHD (HR, 1.33; 95% CI, 0.99-1.80) in participants with a pattern of midlife normotension and late-life hypertension with effective BP control. A higher risks of death and CHD were found in those with pattern of mid- to late-life hypertension with effective BP control (all-cause mortality: HR, 1.24; 95% CI, 1.08-1.43; CHD: HR, 1.65; 95% CI 1.30-2.09), pattern of midlife normotension and late-life hypertension with poor BP control (all-cause mortality: HR, 1.27; 95% CI, 1.12-1.44; CHD: HR, 1.53; 95% CI, 1.23-1.92), and pattern of mid- to late-life hypertension with poor BP control (all-cause mortality: HR, 1.49; 95% CI, 1.30-1.71; CHD: HR, 1.87; 95% CI, 1.48-2.37). Conclusions: The current findings underscore that the management of elderly hypertensive patients should not merely focus on the current BP status, but the middle-aged BP status. To achieve optimal reductions in the risk of CHD and death, it may be necessary to prevent, diagnose, and manage of hypertension throughout middle age.

The predictive value of the HEART and GRACE scores for major adverse cardiac events in patients with acute chest pain.

The history, electrocardiogram, age, risk factors, troponin (HEART) and global registry of acute coronary events (GRACE) scoring systems are commonly used to risk stratify patients with chest pain. This study investigated the application of these scores in predicting the short-term risk of a major adverse cardiac event (MACE) in patients with chest. A total of 509 patients were analyzed. All patients were followed up for 30 days after visiting our emergency department. At 30 days post-admission, the primary outcome (MACE) was recorded in 92 patients (18.1%), 88 (95.6%) of whom had experienced an acute myocardial infarction. Thirty-seven (40.2%) of the patients with a MACE underwent percutaneous coronary intervention and six patients (6.5%) died. The HEART and GRACE scores were both significantly higher in patients who developed a MACE than in those without (P < 0.05). The HEART and GRACE scores had c-statistic values of 0.811 (95% CI 0.774-0.844) and 0.648 (95% CI 0.603-0.688), respectively. The Hosmer-Lemeshow statistic revealed that the HEART and GRACE scores had values of 8.68 (P = 0.39) and 10.45 (P = 0.11), respectively. The percentages of patients with HEART scores of 0-3, 4-6, and 7-10 were 3.0%, 26.2%, and 46.3%, respectively, in those with a MACE within 30 days. The findings show that while both scoring systems are useful, the HEART score is superior to the GRACE score for predicting the occurrence of MACE within 30 days in patients with chest pain.

Antiplatelet strategy in primary and secondary prevention of cardiovascular disease in patients with type 2 diabetes mellitus: A perspective from the guideline appraisal.

AIMS/INTRODUCTION: To appraise guidelines on the antiplatelet strategy of prevention of cardiovascular disease (CVD) in patients with type 2 diabetes mellitus, and highlight the consensuses and controversies to aid clinician decision-making. MATERIALS AND METHODS: A systematic search was carried out for guidelines regarding CVD prevention or focusing on type 2 diabetes patients. Appraisal of Guidelines for Research and Evaluation II instrument was utilized to appraise the quality of included guidelines. RESULTS: Of the 15 guidelines with discrepant Appraisal of Guidelines for Research and Evaluation II scores (66%; interquartile range 51-71%), 10 were defined as "strongly recommended" guidelines. For secondary prevention, >60% of guidelines advocated that the dual antiplatelet therapy was used within 12 months when the type 2 diabetes patients experienced acute coronary syndrome and/or post-percutaneous coronary intervention or coronary artery bypass grafting, with subsequent long-term aspirin use. For primary prevention, 80% of guidelines supported that aspirin should not be routinely used by patients with type 2 diabetes. No consensus on whether to prolong dual antiplatelet therapy in secondary prevention, and whether to use aspirin in type 2 diabetes patients with high CVD risk exists in current guidelines. CONCLUSIONS: Physicians should use the recommendations from "strongly recommended" guidelines to make informed decisions and know the consensuses of current guidelines. Dual antiplatelet therapy should be used within 12 months when type 2 diabetes patients experience acute coronary syndrome and/or percutaneous coronary intervention/coronary artery bypass grafting, with subsequent long-term aspirin use. In primary prevention, aspirin should not be routinely used by individuals with type 2 diabetes, but might be considered for those with high CVD risk.

Automatic annotation of local activation time was improved in idiopathic right ventricular outflow tract ventricular arrhythmia by novel electrogram "Lumipoint" algorithm.

PURPOSE: Precise automatic annotation of local activation time (LAT) is crucial for rapid high-density activation mapping in arrhythmia. However, it is still challenging in voltage-transitional areas where local low-amplitude near-field potentials are often obscured by large far-field potentials. The aim of this study was to explore the viability and validity of automatic identification of the earliest activation (EA) in idiopathic right ventricular outflow tract ventricular arrhythmias (RVOT VAs) using a novel Lumipoint algorithm. METHODS AND RESULTS: Twenty-seven patients with RVOT VAs were mapped with Rhythmia mapping system. Lumipoint algorithms were applied to reannotate the initial activation regions retrospectively. The results showed that LATs were reannotated in 35.0 ± 11.4% points in the initial activation area from bipolar activation breakout time (BBO) to the its 40 ms earlier timepoint. The automatically determined bipolar earliest activation time after Lumipoint reannotation (BEAT-lu: - 111.26 ± 12.13 ms) was significantly earlier than that before (BEAT: - 108.67 ± 12.25 ms, P = 0.000). Compared with manually corrected earliest activation time (EAT), the difference between EAT and BEAT-lu (DEAT-BEAT-lu: 6 (2-7) ms) was significantly smaller than that between EAT and BEAT (DEAT-BEAT/DEAT-UEA: 7 (4-11) ms, P = 0.000). The incidence of EAT and BEAT-lu being the same site was significantly higher than that between EAT and BEAT (48.15% vs 18.52%, P = 0.021). CONCLUSIONS: RVOT VAs often originate from voltage-transitional zone, and automatic annotation of LAT usually located at later high-amplitude far-field potential. Lumipoint algorithms could improve the accuracy of LAT automatic annotation, and it was plausible to ablate RVOT VAs just according to the automatically annotated BEAS-lu.

A systematic review of guidelines for dual antiplatelet therapy in coronary artery bypass graft.

BACKGROUND: In most situations, many patients undergoing coronary artery bypass graft (CABG) are on dual antiplatelet therapy (DAPT), which is also required after CABG. The adjustment of antiplatelet strategy remains controversial. In this study, we systematically review current guidelines, seeking consensus and controversies to facilitate clinical practice. METHODS AND RESULTS: Guidelines are searched in PubMed, Embase, ECRI Guidelines Trust and websites of guidelines organizations and professional society. Guidelines with recommendations of DAPT for patients undergo CABG are included. Two reviewers appraised guidelines with the Appraisal of Guidelines for Research and Evaluation II (AGREE II). Relevant recommendations are extracted and summarized. A total of 14 guidelines meeting inclusion criteria are selected, with average AGREE II scores from 44% to 86%. Most guidelines score high in domains other than 'applicability'. Many guidelines are not detailed enough in reporting considerations behind recommendations. Current guidelines are consistent on the management of antiplatelet strategy before elective CABG and using DAPT after surgery for preventing graft vessel occlusion. Evidence is still lacking in urgent CABG and resumption of the previous DAPT after surgery. CONCLUSIONS: Current guidelines on DAPT in CABG are generally satisfying. Suspending P2Y12 inhibitors while aspirin continued before elective CABG is recommended, as well as 12 months of DAPT following CABG. More evidence is needed to guide antiplatelet therapy in urgent CABG and to prove the benefits of resuming previous DAPT.

Six-Year Change in QT Interval Duration and Risk of Incident Heart Failure　- A Secondary Analysis of the Atherosclerosis Risk in Communities Study.

BACKGROUND: Few studies have investigated the association between temporal change in QT interval and incident heart failure (HF). The aim of this study is to examine this association in the Atherosclerosis Risk in Communities (ARIC) study.Methods and Results:A secondary analysis was performed for the ARIC study. Overall, 10,274 participants (age 60.0±5.7 years, 45.7% male and 19.5% black) who obtained a 12-lead electrocardiography (ECG) at both Visit 1 (1987-1989) and Visit 3 (1993-1995) in the ARIC study were included. QT interval duration was corrected by using Bazett's formula (QTc). The change in corrected QT interval duration (∆QTc) was calculated by subtracting QTc at Visit 3 from Visit 1. The main outcome measure was incident HF. Multivariable Cox regression models were used to assess the association between ∆QTc and incident HF. During a median follow up of 19.5 years, 1,833 cases (17.8%) of incident HF occurred. ∆QTc was positively associated with incident HF (HR: 1.06, 95% CI 1.03, 1.08, per 10 ms increase, P<0.001; HR 1.22, 95% CI 1.08, 1.36, T3 vs. T1, P=0.002), after adjusting for traditional cardiovascular risk factor, QTc and QRS duration. CONCLUSIONS: Temporal increases in QTc are independently associated with increased risk of HF.

In vivo intravascular photoacoustic imaging at a high speed of 100 frames per second.

Intravascular photoacoustic (IVPA) imaging technology enables the visualization of pathological characteristics (such as inflammation activities, lipid deposition) of the artery wall. Blood flushing is a necessary step in improving the imaging quality in in vivo IVPA imaging. But the limited imaging speed of the systems stretches their flushing time, which is an important obstacle of their clinical translations. In this paper, we report an improvement in IVPA/IVUS imaging speed to 100 frames per second. The high-speed imaging is demonstrated in rabbit in vivo, visualizing the nanoparticles accumulated on abdominal aorta wall at the wavelength of 1064 nm, in real time display. Blood flushing in vivo improves the IVPA signal-noise-ratio by around 3.5 dB. This study offers a stable, efficient and easy-to-use tool for instantaneous disease visualization and disease diagnosis in research and forwards IVPA/IVUS imaging technology towards clinical translations.